Ga. Medicaid Part II Policies & Procedures for Hospital Services, Appendix J

The prospective reimbursement system for inpatient hospital services is described in Chapter 1000 of this manual.

In addition to the specific per case rate amount, an enrolled Georgia or non-Georgia hospital which has an

unusually costly admission (or admissions) during the reimbursement year may obtain additional reimbursement

for that admission under circumstances described below. This additional reimbursement, determined on a case-by-case basis, may be granted if the cost of the admission in question exceeds the established threshold.

To obtain additional reimbursement for an unusually expensive admission (cost outlier), the claim must first

qualify as an outlier with edit code 4399 which is documented on the Remittance Advice (RA). Effective 10/1/16,

Gainwell Technologies will no longer accept any paper Outlier Requests. The Outlier request is to be submitted

electronically to Alliant/GMCF by the GAMMIS web portal under Provider Workspace/Medical Review Portal,

under “Outlier Reviews”.

The hospital must submit the required information which will be displayed at the time of the electronic request.

The itemized bill is required for ALL Outlier requests. Requests submitted without the required documentation

will not be accepted. If the request and all required documentation is not received within (90) days from the paid

(RA) in which the Division reimburses the case rate, outlier payment will be denied.

Once an outlier request has been submitted to Alliant/GMCF for review, the providers CAN NOT void the claim

via the web. Providers who repeatedly request adjustments or voids generating the need for a positive adjustment

may be subject to adverse action by the Division.

A. Itemized Charges for Admission

The itemized bill must be submitted in the following formats indicated below. A sample template

is available under the Outlier Review tab.

i. XML

ii. Excel

1. Excel Worksheet should be named “Sheet1”

iii. The column headers should be as follows:

1. ACCOUNT_NUMBER, DATE_OF_SERVICE, REVENUE_CODE,

2. ITEM_NUMBER, DESCRIPTION, QUANTITY, AMT_BILLED

iv. Files should only contain data elements only (no formatting, ie. no blank rows, no page

numbers, headers, footers)

v. Failure to submit the Excel file in the required format will result in a denial

ACCOUNT_

NUMBER

DATE_OF_

SERVICE

REVENUE

_CODE

ITEM_NUMBER

DESCRIPTION

QUANTITY

AMT_

BILLE

D

123456789 4/5/2016 164 16000000 ISOLATION MED SURG 1 $2,10

0.00 123456789 4/6/2016 164 16000000 ISOLATION MED SURG 1 $2,10

0.00 123456789 4/5/2016 113 15000000 HCHB R&B PRIVATE 1 $938.

00 123456789 4/6/2016 113 15000000 HCHB R&B PRIVATE 1 $938.

00

123456789

4/5/2016

250

24000000

OMEPRAZOLE 40 MG

CAP, DELAYED RELEASE

1

$25.7

5

123456789

4/6/2016

250

24000000

OMEPRAZOLE 40 MG

CAP, DELAYED RELEASE

1

$25.7

5 123456789 4/6/2016 270 20000000 BIOPSY SET, LIVER 1 $1,95

0.00

123456789

4/5/2016

301

30000000

COMPREHENSIVE

METABOLIC PANEL

1

$251.

00

123456789

4/6/2016

301

30000000

COMPREHENSIVE

METABOLIC PANEL

1

$251.

00 123456789 4/6/2016 360 36000000 BIOPSY LIVER NEEDLE PERC 1 $1,60

0.00

vi. The itemization must be listed by revenue code.

vii. The revenue codes included on the itemized bill must match the revenue codes on the

claim and UB-04.

viii. The itemized bill revenue totals must match the billed revenue totals on the claim and

UB-04. The totals billed must match.

Example: revenue 301 billed amount on the claim and UB04 of $3,265.00 but the billed

amount on the itemized bill of $3,465.00. The billed amount on the itemized bill is

greater than the billed amount on the claim and UB04.

ix. Each item must contain the description, quantity (units) billed, and the charge for that

item. Itemizations that reflect rolled up charges into one-line item will be denied.

x. There cannot be any zero charge items on the itemized bill. The billed amount on the

itemized charges and UB claim form must be in agreement.

xi. Negative charges should not be submitted/included on the itemized bill.

xii. Claim revenue codes should not be listed individually. All charges for the revenue code

should be billed as one line.

Example: revenue 250, 250, 250, 250, 250, instead revenue code 250 should only be

billed once.

xiii. Hospital Acquired Conditions/Never Events must be highlighted or marked through from

the itemized claim unless on exception list. (See Section 1102. E of Part II Policies and

Procedures for Hospital Services Manual for these exceptions).

xiv. The electronic files are labeled for review and only the documents listed are submitted.

xv. The request is submitted within the 90-day deadline of the paid RA.

xvi. The UR notes must be signed and dated on the review date with Severity of

Illness/Intensity of Service (SI/IS) criteria indicated or indicate the guideline stage and

progression to next day. UR notes must indicate the severity of illness/intensity of service

(SI/IS) that was met for medical necessity of the hospital stay and must be written

concurrently on the review date. Failure to document the SI/IS criteria (met/not met) in

the utilization review notes may result in the denial of your DRG outlier request. The UR

notes must adhere to the frequency indicated in the UR Plan.

xvii. When the Outlier request is submitted, the system will identify which documents are

needed for the review. The itemized bill is required for all requests. Additional

information may be requested. Only the requested documentation should be submitted. If

the entire medical record is submitted, the request will be denied.

xviii. All charges to be considered for additional reimbursement must be in a paid status in the

claims processing system prior to submission of the outlier request. Claims for which a

third party pays at or in excess of the DRG payment are not to be billed to the Division;

therefore, cost outlier reimbursement for such claims is not available. Any services listed

on the itemized charges and not billed to the Division must be identified by the hospital.

The billed amount on the itemized charges and UB claim form must be in agreement.

xix. For a claim to meet the criteria for consideration of additional reimbursement, the

submitted utilization review notes must demonstrate compliance with the hospital’s

Utilization Review Plan on file and approved by the Division. Hospital utilization review

programs must include review of the medical necessity for admission, the appropriateness

of services and the medical necessity for continued stay. If this frequency is not followed,

this may result in a denial.

xx. In some cases additional information is required to complete the review process. When

additional information not identified above is requested, it must be received within (30)

days of the date of the paid RA request. If not received by the due date, the request for

outlier payment will be denied.

xxi. Hospitals billing for services provided through contractual shared agreements are

responsible for submitting a combined itemized bill of both hospitals itemized charges

and both set of documents for review if required

xxii. Second and Administrative requests are to be requested the same way listed above with

30 days of the review determination denial letter or within 30 days of the paid RA date.

xxiii. It is the responsibility of the provider to assure that each and every outlier claim and all

information necessary to complete the review is received by the Division or its agent.

xxiv. Your Outlier request’s status may be viewed on the GAMMIS web portal under the

Provider Workspace/Medical Review Portal, under “Outlier Reviews”. Questions

regarding your Outlier may be sent to GMCF via Provider Workspace/Medical Review

Portal under “Contact Us”. Please refer to the “Provider Education and Training” link for

instructions.

xxv. Calculation of reimbursement for claims that meet outlier criteria is discussed in Chapter

1000 for Reimbursement

xxvi. Day Outlier For dates of admission on or after October 9, 1997, there is no longer an

outlier policy for day outliers.

B. Required Outlier Documents Checklist

When the Outlier request is submitted, the system will identify which documents are required for

the review. All requests must have an itemized bill submitted. Only the requested documents

should be submitted for the review. If the entire record is submitted the Outlier request will not be

reviewed, and the provider must resubmit the Outlier record with only the required documents.

i. All Outlier Requests:

1. File format should be one of the following: Itemized bill:

a) XML

b) Excel

2. Excel Worksheet should be named “Sheet1”

3. The column headers should be as follows:

a) ACCOUNT_NUMBER

b) DATE_OF_SERVICE

c) REVENUE_CODE

d) ITEM_NUMBER

e) DESCRIPTION

f) QUANTITY

g) AMT_BILLED

Files should only contain data elements (no formatting)

Billed amount on the itemized charges and UB claim form must be in agreement. The revenue

codes included on the itemized bill must match the revenue codes on the claim and UB-04. The

itemized bill revenue totals must match the billed revenue totals on the claim and UB-04. The

totals billed must match. Negative and zero charges should not be submitted/included on the

itemized bill.

Claim revenue codes should not be listed individually. All charges for the revenue code should be

billed as one line. Example: revenue 250, 250, 250, 250, 250, instead revenue code 250 should

only be billed once.

C. Additional Documents that may be required:

i. Cover Letter:

1. Indicates initial, second or administrative request

2. Includes the members’ name, member number and dates of service. (If this

information does not match the RA, an explanation needs to be provided.)

3. Contact person name, e-mail address and phone number.

ii. Claim - UB form:

1. The billed amounts

iii. Utilization Review (UR) Notes:

1. Signed and dated on the review date

2. Severity of Illness/Intensity of Service (SI/IS) criteria indicated (met/not met)

guideline stage and progression to the next day

3. Physician Discharge Summary

4. Physician Progress Notes

5. Operative (OP/OR) Procedure Notes (if applicable)

Gainwell Technology

Special Handing Documents

P.O. Box 105208 Suite 750

Atlanta, Georgia 30085-5208

D. REQUIRED OUTLIER DOCUMENTS CHECKLIST

The following items must be submitted as outlined below for Outlier review. Only required chart

documents should be submitted for review. If the entire chart is submitted the record will not be

reviewed and the provider must resubmit the Outlier record with only the required documents.

i. Cover Letter includes:

1. Member name and number

2. Contact Person, number and e-mail address.

3. Member name, member number and dates of service.

4. (If this information does not match the RA, an explanation needs to be provided.)

5. ICN

6. Initial request, second request or administrative request.

ii. Claim – UB form:

Claims a third party pays at or in excess of the DRG payment are not to be billed to the Division.

Itemized Bill - Excel Format containing the following:

1. Column headers should be as follows:

a) ACCOUNT_NUMBER

b) DATE_OF_SERVICE

c) REVENUE_CODE

d) ITEM_NUMBER

e) DESCRIPTION

f) QUANTITY

g) AMT_BILLED

2. Excel Worksheet tab should be named “Sheet1”

3. Files should only contain data elements only (no formatting, ie. no blank rows,

no page numbers, headers, footers, etc.)

4. Total charges and DOS match on itemized bill, RA and UB-04 unless a HAC/

Never Event is present. HAC/Never Events should be highlighted or crossed out.

5. Billed charges on the itemized bill and revenue codes match the UB-04.

6. Charges documented in the itemized bill but not billed on the UB-04 are

identified and marked through on the itemized bill.

ii. Utilization Review (UR) Notes includes:

1. Inpatient review criteria (Met/Not Met) indicated for each review date or indicate

the guideline stage and progression to the next day

2. Indicate the name and title of the reviewer

3. Signed by the reviewer on the review date. Retro entries are not acceptable.

4. Adhere to the frequency indicated in the UR plan

iii. Physician Progress Notes:

1. Physician Discharge Summary

2. Operative (OP/OR) Procedure Notes (if applicable)

3. Request submitted within 90-day deadline of paid RA

Completed by: Date of completion: